O.T.R.A. ROADSIDE SERVICES, INC.
New Customer Questionnaire
Company Name:
*
First Name:
*
Last Name:
Phone:
*
Email:
New Unit Questionnaire
What type of chassis is this unit:
*
Select Unit Type
Box Truck
Bus
Heavy Equipment
Pick-Up Truck
RV - Recreational Vehicle
Tractor
Trailer
Travel Trailer / Fifthwheel
VIN
:
Year:
Make:
Model:
Unit Number:
Unit Nickname:
License Plate:
Service Request Questionnaire
Complaints / Problems / Requests
Describe first complaint, problem, or request:
*
How urgent is this:
*
Schedule as soon as possible
Schedule repair today
Emergency - Get this fixed right away
Remember for the next visit
Add another
Scheduling & Authorization
When will the unit be available for repairs:
Now
The unit MUST be accessed at the above date and time.
When would you like the unit back:
Return ASAP
How would you like us to access the unit:
*
Select Access Method
No preference, just get it done!
Customer will bring unit to the shop
Shop will service unit on-site
Shop will pick up unit and bring to the shop
Shop will tow unit
Where will this unit be located for access:
*
Select Address
Temporary Address (please put address in the Helpful Notes below)
Add A New Address
Street Address:
*
Street Address 2:
City:
*
Country:
*
United States
Canada
Australia
China
Dominican Republic
Germany
Greece
Hong Kong
Mexico
Puerto Rico
Saint Lucia
State:
*
Postal Code:
*
Address Name:
*
Save
Cancel
Would you like the shop to deliver the unit:
*
No - Customer will pick up unit from shop
Yes - Shop will return unit to customer
Where would you like this unit delivered:
*
Select Address
Temporary Address (please put address in the Helpful Notes below)
Add A New Address
Street Address:
*
Street Address 2:
City:
*
Country:
*
United States
Canada
Australia
China
Dominican Republic
Germany
Greece
Hong Kong
Mexico
Puerto Rico
Saint Lucia
State:
*
Postal Code:
*
Address Name:
*
Save
Cancel
Authorization Number:
PO Number:
Notes and Instructions For Shop:
Step 4: Additional Information:
Unit Identifier:
Driver Name / #:
Engine:
Reference #:
Payment Method:
Select Payment Method
ACH
American Express
Cash
Check
Comchek
Credit
Credit Card
Debit Card
Discover
E-Check
EFS
EFT
Fleet One
Gift Card
Internal Payment
MasterCard
National Account Credit
PayPal
Payroll Deduction
T -Check
Third Party
Visa
How did you hear about us (e.g. shop website):
Submit